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Poindexter Is Now VP CLAIMs Insights!
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Blog & News

Part 1 – Kidney Failure and Dialysis – What Employers, Health Plans, TPAs and Nurse Care Managers Need to Know

Joy McGee-Cory – Senior Vice President, Advanced Plan for Health & Barbara Rutkowski, EdD, MSN, CCM – Vice President, Clinical Operations, Advanced Plan for Health

Kidney failure and life-saving dialysis are both a catastrophic health plan expense and life-changing experience that impact health plans and lives through probability.  The incidence of chronic kidney / renal disease is about 2 to 2.5 per 1,000 members across the APH customer base. Because lady luck is elusive, lightning can strike twice for the same health plan, resulting in typical annual health plan expenditures between $350,000 and $700,000 for each member on dialysis. According to the National Kidney Foundation, more than 660,000 Americans have end stage renal disease (ESRD), meaning that their kidneys have permanently failed, and dialysis is required to cleanse the toxins from their bodies.

The University of California San Francisco states that number is increasing by 5 percent each year especially in the minority and lower income groups.  They shared that some dialysis patients qualify for kidney transplants, but there are about 100,000 on the waiting list and only 20,000 available kidneys, and the individual need for kidneys for transplantation keeps rising at nearly 8 percent annually!

Greater Insight Is Needed to Optimize the Trend

Advanced Plan for Health (APH) has the tools and information that help employers, health plans, TPAs and nurse care managers proactively address kidney disease through Poindexter, an intelligent longitudinal and predictive analytics system. Poindexter blends vital claims data, biometrics, benchmarks and predictive modeling capability together to serve up easy-to-read clinical triggers, utilization trends, customized reports and care gaps.  Making affected individuals and groups easy to find, monitor and measure for the impact of care management interventions in relation to a multiyear baseline.

APH’s readily accessible tools identify kidney disease early, predict costs and events such as the likelihood of cardiac events or hospitalization, and APH has a special high-risk category for plan members whose kidney function is failing, so that intensive nurse care management can be initiated early to prevent dialysis and the high costs of kidney disease.

APH also provides nurse care managers with the tools to set mutual goals between the provider and member. Tracking tools optimize compliance by monitoring how well the member is following the physician’s treatment plan in areas such as – setting and achieving applicable care gap goals, filling medications, monitoring biometric values, and following national best practice benchmarks (which are hardwired into Poindexter for comparative purposes).

This means that the care management team can point and click to see if an individual is compliant and moving forward with pre-set Clinical, Cost and Utilization Plan goals and if the mutually set patient lifestyle modification and stabilization goals are working.  If they are not, Poindexter has the tools, simple accessibility, ease in report creation and understandable feedback needed to identify and rework the goals with the affected individual and providers in a collaborative manner until the best outcomes are achieved.  In short, Poindexter supports continuous performance improvement and kaizen.

APH is focused on measurable outcomes and results, and as a result we strongly emphasize and detail results clinically and financially. Poindexter provides the information to create an approach that is both flexible and scientific because the necessary analytics are just a point and click away, permitting health professionals to keep each member’s health practices on track. It also arms TPAs with data to spot trends that underlie prudent contracting, steerage and medically necessary resource utilization. By using these tools nurse care managers and TPAs can personalize outreach, monitor progress and measure results, according to their scope of practice / business.

Steps in Supporting the Wellness and Medical Management Continuum

Step one is prevention.  Individuals with diabetes, obesity, hypertension and hyperlipidemia are some individuals most commonly at higher risk of developing renal disease, especially if they don’t live a healthy lifestyle, and follow their physician’s treatment plan to prevent and / or control their chronic health conditions.  Did you know that nearly 10 percent of American adults age 20 or older have some level of chronic kidney disease?  Statistics show that 1 in 3 diabetics and 1 in 5 hypertensive patients have some degree of chronic kidney disease. The unfortunate truth is that hypertension and chronic kidney disease progression are silent and progressive, unless well managed.

In one case, Mary*, an employee with malignant hypertension, was not taking her blood pressure medication, because she had limited income and she did not “feel bad,” so was unaware of how this “silent killer” was endangering her life and health.  She often chose between her medication and ensuring that her son had clothes, shoes and sports supplies like other children, and paying rent. Since she could not feel any signs of high blood pressure, she had not filled her prescription at all in the months since her doctor had prescribed it for her. Her extreme, malignant blood pressure reading was caught at a biometric screening, and the nurse care manager was able to educate her and get her a prescription filled for a well-established generic medication with a low co-payment that same day.  For Mary, this was a move that minimized her danger of having a stroke, damaging her kidneys or some other such calamity that could have caused disability or worse.

APH has the analytics to follow individuals in diagnostic groups, like Mary, and others across groups of discrete and aggregated conditions and demographics through Poindexter. The goal is to identify those needing outreach, lacking a primary care physician, using out of network providers, or incurring high costs. The system also identifies those who are not following best medical practices in caring for themselves.

Many employers have biometric screenings and healthy contests and activities in the workplace, which are good in building a health-conscious culture integral to the long-term success of individuals and businesses. These positive activities need to be sustained and built into future programs, when a chronic care management component is added to enhance member health and conserve health plan resources.

Step two is disease or chronic care management.  Nurse care management is directly attributed to improved measurable clinical statistics and bottom-line financial outcomes. Individuals targeted for intervention have established diagnoses, and may not be in compliance with their treatment plan.  Further, they may be wasting resources by seeking episodic care in the emergency room and / or being admitted to the hospital due to letting their health issues get out of control.  Poindexter identifies these targeted groups of individuals, including those with harmful health practices and potentially preventable utilization, so that nurse care managers can follow-up to engage these individuals and bring them into compliance.

Poindexter identifies members with failing kidneys starting at Stage 1.  These members with early chronic kidney disease, hypertension and / or diabetes need to be aggressively targeted, educated and managed, because kidney disease progression can be prevented and dialysis can usually be avoided with excellent medical management.

For missed cases – new plan members and those who have continued their downhill course toward end stage renal disease (ESRD) – Poindexter identifies the high-risk group of members with Chronic Kidney Disease (CKD) again specifically at Stage 3, so that nurse care managers can intervene more aggressively to slow the progression to ESRD.  At stage 3 or 4, individuals are at very high risk for kidney failure, and may have bouts of acute kidney failure and expensive hospitalizations with intensive care. These members need aggressive personalized professional help on a continuing basis to control their chronic health conditions and optimize their lifestyle, thereby avoiding and / or delaying end stage renal disease and ongoing renal dialysis.

To learn more about how Poindexter and the APH team of expert analytics and clinical experts can help you identify and address Kidney Disease as early as possible, please contact us here and we’d be happy to connect to learn more about your needs.

This is a multi-part blog series.
Part two will cover – Preparing for a Kidney Transplant or Dialysis.

*Member name changed to protect privacy.


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